Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Esophagus
Question 1#

A 65-year-old man with a history of reflux disease experiences chest discomfort after undergoing an upper endoscopy for surveillance. The patient is hemodynamically stable and a gastrografin esophagram confirms a small contained perforation in the mid esophagus with minimal contamination in the mediastinum.

The most appropriate initial therapy consists of:

A. Thoracotomy with primary repair and appropriate drainage
B. Esophagectomy with immediate reconstruction
C. Esophageal stent placement
D. Diversion cervical esophagostomy

Correct Answer is C


Correct Answer: C

Iatrogenic esophageal perforation can be a catastrophic complication of upper endoscopy. The incidence of perforation due to rigid endoscopy approaches 0.1% to 0.4% while that of flexible endoscopy varies from 0.01% to 0.06%. Perforation rates increase when additional interventions are performed such as balloon dilation. The timing of perforation is critical in managing the morbidity and mortality of this complication. Initial operative mortality rates approach 12% to 50%; however, a delay in management of 12 to 24 hours can significantly increase morbidity and mortality. The postoperative suture breakdown rate can reach 50% if repair is delayed beyond 24 hours.

Treatment of esophageal perforation requires multimodal therapy with intravenous antibiotics, nothing per mouth (NPO), isolating the area of the leak, and providing adequate nutrition either enterally via gastrostomy or intravenous therapy. Blind nasogastric tube insertion is discouraged as it may further damage the injured esophagus. 

Hemodynamically stable patients with a contained perforation can be treated endoscopically with the placement of an esophageal stent to contain the leak and prevent further contamination. Depending on the location of the esophageal perforation, success rates with stent placement approach 80% to 90% in some series, allowing healing of the injured esophagus. Furthermore, stenting carries the lowest morbidity and mortality of all options available for treatment of esophageal perforation, challenging the old dogmatic teaching of primary repair as the “gold standard.”


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  2. Dasari BV, Neely D, Kennedy A, et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg. 2014;259:852-860.